NURS 525 EXAM 2 ELSEVIER QUESTIONS &
ANSWERS
Skin inspection and palpation includes assessment for:
A. Color, uniformity, and symmetry
B. Skin lesions
C. Skin temperature
D. All of the above - Answer -D. All of the above
An ABNORMAL angle between the nail base and the nail is called clubbing and may
indicate which of the following conditions?
A. Poor hygiene
B. Dehydration
C. Cardiopulmonary disorder
D. Skin cancer - Answer -C. Cardiopulmonary disorder
Which are the best places to check the skin for tenting, which is a sign of dehydration?
A. Top of the hand and foot
B. Neck and top of the head
C. Shoulder and thigh
D. Forearm and sternum - Answer -D. Forearm and sternum
Which of the following is considered an ABNORMAL finding in an older adult?
A. Malignant melanoma
B. Cherry angioma
C. Seborrheic keratoses
D. Lentigines - Answer -A. Malignant melanoma
The ABCD rule of melanoma includes:
A. Asymmetry of shape
B. Border irregularity and color variation
C. Diameter larger than the eraser of a pencil
D. All of the above - Answer -D. All of the above
What is the correct order for abdominal assessment?
A. Inspection, palpation, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, palpation, percussion
D. Palpation, inspection, auscultation, percussion - Answer -B. Inspection, auscultation,
percussion, palpation
How often should normal bowel sounds be heard in each quadrant of the abdomen?
A. 5-35 times per minute
B. Less than 5 times per minute
,C. 15-20 times per minute
D. 20-40 times per minute - Answer -A. 5-35 times per minute
Which of the following is an important part of performing an abdominal assessment?
A. Completing the assessment as quickly as possible
B. Stopping the assessment if the patient has any tenderness
C. Explaining each step of the assessment to the patient
D. Having the patient talk when auscultating for bowel sounds - Answer -C. Explaining
each step of the assessment to the patient
What should you do if a patient is ticklish when you are palpating the abdomen?
A. Distract the patient by talking to him or her.
B. Do not palpate the abdomen in the upper quadrants.
C. Do only deep palpation of all four quadrants.
D. Place your hand over the patient's hand during palpation. - Answer -D. Place your
hand over the patient's hand during palpation.
Moderate and deep palpation of the abdomen:
A. May cause tenderness
B. Should not detect masses
C. Should never be done over a surgical incision
D. All of the above - Answer -D. All of the above
A nurse is palpating the breasts of a patient. Which of the following are important
aspects of proper palpation of the breasts?
A. Using finger pads to palpate
B. Using a consistent pattern
C. Making small circles at each part of the breast and gliding from place to place
D. All of the above - Answer -D. All of the above
What is the most important information to document if a mass is palpated in the breast
or axilla?
A. Color and tenderness of surrounding tissue
B. Shape, tenderness, mobility, and size of the breasts
C. Consistency, borders, mobility, location, size, shape, tenderness, and retraction of
the mass
D. Characteristics of the nipple and lymph nodes - Answer -C. Consistency, borders,
mobility, location, size, shape, tenderness, and retraction of the mass
What are the five danger signs to watch for when assessing nipples?
A. Shape, tenderness, size, inversion, and mobility
B. Discharge, depression, discoloration, dermatologic changes, and deviation
C. Lymph nodes, breast size, symmetry, tail of Spence, and color
D. Rash, nodules, warmth, redness, and pain - Answer -B. Discharge, depression,
discoloration, dermatologic changes, and deviation
, Which of the following statements is the most complete description of the tail of
Spence?
A. Breast tissue that extends into the axilla
B. A common place to find breast lumps
C. Not included in a breast exam
D. Both A and B - Answer -D. Both A and B
When assessing the breasts, which of the following is considered normal?
A. Long-standing, unchanging nevi
B. Reddened Montgomery glands
C. Peau d'orange skin texture
D. Nipples that are not symmetrical - Answer -A. Long-standing, unchanging nevi
Which of the following indicates normal respiratory function?
A. Symmetrical chest expansion
B. Nasal flaring
C. Use of accessory muscles
D. Lip pursing - Answer -A. Symmetrical chest expansion
When palpating the thorax, which of the following would be an abnormal finding?
A. Tenderness
B. Pulsations
C. Masses
D. All of the above - Answer -D. All of the above
When percussing the thorax, which of the following would be a normal finding?
A. Dullness over the lung fields
B. Resonance over the lung fields
C. Dullness over the ribs, heart, and diaphragm
D. Both B and C - Answer -D. Both B and C
Normal breath sounds include:
A. Vesicular sounds
B. Rhonchi
C. Wheezes
D. Crackles - Answer -A. Vesicular sounds
When auscultating the lungs, it is important to:
A. Compare each side bilaterally.
B. Note abnormal sounds.
C. Ask the patient to take slow, deep breaths.
D. All of the above. - Answer -D. All of the above
A patient has edema and redness of the skin surrounding the nail on his right index
finger. Which data elicited from his history best explains this condition?
A. He has a family history of fungal infections of the nails
ANSWERS
Skin inspection and palpation includes assessment for:
A. Color, uniformity, and symmetry
B. Skin lesions
C. Skin temperature
D. All of the above - Answer -D. All of the above
An ABNORMAL angle between the nail base and the nail is called clubbing and may
indicate which of the following conditions?
A. Poor hygiene
B. Dehydration
C. Cardiopulmonary disorder
D. Skin cancer - Answer -C. Cardiopulmonary disorder
Which are the best places to check the skin for tenting, which is a sign of dehydration?
A. Top of the hand and foot
B. Neck and top of the head
C. Shoulder and thigh
D. Forearm and sternum - Answer -D. Forearm and sternum
Which of the following is considered an ABNORMAL finding in an older adult?
A. Malignant melanoma
B. Cherry angioma
C. Seborrheic keratoses
D. Lentigines - Answer -A. Malignant melanoma
The ABCD rule of melanoma includes:
A. Asymmetry of shape
B. Border irregularity and color variation
C. Diameter larger than the eraser of a pencil
D. All of the above - Answer -D. All of the above
What is the correct order for abdominal assessment?
A. Inspection, palpation, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, palpation, percussion
D. Palpation, inspection, auscultation, percussion - Answer -B. Inspection, auscultation,
percussion, palpation
How often should normal bowel sounds be heard in each quadrant of the abdomen?
A. 5-35 times per minute
B. Less than 5 times per minute
,C. 15-20 times per minute
D. 20-40 times per minute - Answer -A. 5-35 times per minute
Which of the following is an important part of performing an abdominal assessment?
A. Completing the assessment as quickly as possible
B. Stopping the assessment if the patient has any tenderness
C. Explaining each step of the assessment to the patient
D. Having the patient talk when auscultating for bowel sounds - Answer -C. Explaining
each step of the assessment to the patient
What should you do if a patient is ticklish when you are palpating the abdomen?
A. Distract the patient by talking to him or her.
B. Do not palpate the abdomen in the upper quadrants.
C. Do only deep palpation of all four quadrants.
D. Place your hand over the patient's hand during palpation. - Answer -D. Place your
hand over the patient's hand during palpation.
Moderate and deep palpation of the abdomen:
A. May cause tenderness
B. Should not detect masses
C. Should never be done over a surgical incision
D. All of the above - Answer -D. All of the above
A nurse is palpating the breasts of a patient. Which of the following are important
aspects of proper palpation of the breasts?
A. Using finger pads to palpate
B. Using a consistent pattern
C. Making small circles at each part of the breast and gliding from place to place
D. All of the above - Answer -D. All of the above
What is the most important information to document if a mass is palpated in the breast
or axilla?
A. Color and tenderness of surrounding tissue
B. Shape, tenderness, mobility, and size of the breasts
C. Consistency, borders, mobility, location, size, shape, tenderness, and retraction of
the mass
D. Characteristics of the nipple and lymph nodes - Answer -C. Consistency, borders,
mobility, location, size, shape, tenderness, and retraction of the mass
What are the five danger signs to watch for when assessing nipples?
A. Shape, tenderness, size, inversion, and mobility
B. Discharge, depression, discoloration, dermatologic changes, and deviation
C. Lymph nodes, breast size, symmetry, tail of Spence, and color
D. Rash, nodules, warmth, redness, and pain - Answer -B. Discharge, depression,
discoloration, dermatologic changes, and deviation
, Which of the following statements is the most complete description of the tail of
Spence?
A. Breast tissue that extends into the axilla
B. A common place to find breast lumps
C. Not included in a breast exam
D. Both A and B - Answer -D. Both A and B
When assessing the breasts, which of the following is considered normal?
A. Long-standing, unchanging nevi
B. Reddened Montgomery glands
C. Peau d'orange skin texture
D. Nipples that are not symmetrical - Answer -A. Long-standing, unchanging nevi
Which of the following indicates normal respiratory function?
A. Symmetrical chest expansion
B. Nasal flaring
C. Use of accessory muscles
D. Lip pursing - Answer -A. Symmetrical chest expansion
When palpating the thorax, which of the following would be an abnormal finding?
A. Tenderness
B. Pulsations
C. Masses
D. All of the above - Answer -D. All of the above
When percussing the thorax, which of the following would be a normal finding?
A. Dullness over the lung fields
B. Resonance over the lung fields
C. Dullness over the ribs, heart, and diaphragm
D. Both B and C - Answer -D. Both B and C
Normal breath sounds include:
A. Vesicular sounds
B. Rhonchi
C. Wheezes
D. Crackles - Answer -A. Vesicular sounds
When auscultating the lungs, it is important to:
A. Compare each side bilaterally.
B. Note abnormal sounds.
C. Ask the patient to take slow, deep breaths.
D. All of the above. - Answer -D. All of the above
A patient has edema and redness of the skin surrounding the nail on his right index
finger. Which data elicited from his history best explains this condition?
A. He has a family history of fungal infections of the nails
